Arizona Medical Release Form 1
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Medical Release/Activity Permission Form
Pertaining to the involvement in any sanctioned activity of the Admissions Office at Arizona Christian University.

Student Information
Name ______________________________________________________________________Age __________
Address ____________________________________________________________________ Apt __________
City ___________________________________________________ State _______________Zip ___________
Name of Health Insurance ___________________________________________________________________
Insurance Group # ___________________________________________________ I.D. # _________________
Specialist _________________________________________ Health Insurance Phone____________________
Student allergies, chronic illness, or other medical conditions (if any): _________________________________
_________________________________________________________________________________________
Current Medications
Name of Medicine
Dosage/Frequency
Termination